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CLINICAL RESEARCH: ASPIRIN, NON-STEROIDAL ANTI-INFLAMMATORY, AND CAD

Aspirin dose and six-month outcome after an acute coronary syndrome

Martin J. Quinn, MD, PhD^*, Herbert D. Aronow, MD, MPH, Robert M. Califf, MD, FACC, Deepak L. Bhatt, MD, FACC, Shelly Sapp, MS, Neal S. Kleiman, MD, FACC^||, Robert A. Harrington, MD, FACC, David F. Kong, MD, AM, David E. Kandzari, MD and Eric J. Topol, MD, FACC^,*

^* St. Vincents University Hospital, Dublin, Ireland
Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania and Philadelphia Veterans Administration Medical Center, Philadelphia, Pennsylvania, USA
Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
The Duke Clinical Research Institute, Durham, North Carolina, USA
^|| Baylor College of Medicine, Houston, Texas, USA

Manuscript received July 9, 2003; revised manuscript received September 12, 2003, accepted September 29, 2003.

^* Reprint requests and correspondence: Dr. Eric J. Topol, Department of Cardiovascular Medicine, Desk F 25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
topole{at}ccf.org

OBJECTIVES: This study was designed to compare the efficacy of low and intermediate aspirin doses in acute coronary syndromes.

BACKGROUND: Little is known of the comparative efficacy of low and intermediate aspirin doses in this setting.

METHODS: We compared six-month death, myocardial infarction (MI), and stroke in patients with unstable angina or acute MI discharged while receiving low (<150 mg) or intermediate (150 mg) aspirin therapy in the GUSTO IIb and PURSUIT trials (n = 20,521). We used multivariable analysis and performed a propensity analysis in order to adjust for baseline imbalances between the groups.

RESULTS: Aspirin doses <150 mg were prescribed to 29.9% (6,128) of patients. By six months, 6.4% of the patients (1,310 of 20,521) had a primary event, 6.2% of the patients receiving <150 mg and 6.6% of the patients receiving aspirin doses 150 mg (hazard ratio [HR] 1.06 [95% confidence interval (CI) 0.94 to 1.19], p = 0.35). After adjusting for baseline imbalances and the propensity score for discharge aspirin dose, there was no effect of aspirin dose on the composite end point at six months (HR 0.92 [95% CI 0.79 to 1.07], p = 0.28). However, the higher aspirin dose was associated with a reduction in six-month MI (HR 0.79 [95% CI 0.64 to 0.98], p = 0.03). The outcome was similar when patients were matched on the basis of the propensity score for aspirin dose (HR for death/MI/stroke 0.94 [95% CI 0.80 to 1.12], p = 0.51), although stroke occurred significantly more frequently among patients receiving the higher aspirin dose (HR 1.74 [95% CI 1.01 to 3.02] p = 0.05) and the effect on MI was no longer apparent.

CONCLUSIONS: Although these data are non-randomized, they suggest that the aspirin dose upon discharge may influence the clinical course after unstable angina or acute MI.

Abbreviations and Acronyms   ACS = acute coronary syndrome   ALDUSA = Aspirin at Low Dose in Unstable Angina   ATACS = Antithrombotic therapy in Acute Coronary Syndromes Study Group   CARS = Coumadin Aspirin Reinfarction Study   CHAMP = Combination Hemotherapy and Mortality Prevention   CI = confidence interval   DUCCS-II = Duke University Clinical Cardiology Group Study-II   ECG = electrocardiographic   GUSTO IIb = Global Use of Strategies to open Occluded coronary Arteries   HR = hazard ratio   MI = myocardial infarction   PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrelin Therapy   TxA2 = thromboxane A2

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